Provider Demographics
NPI:1093546442
Name:DISSELHORST, JOHN LOUIS
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LOUIS
Last Name:DISSELHORST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:DISSELHORST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4711 N BROADWAY ST STE 105
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4908
Mailing Address - Country:US
Mailing Address - Phone:815-382-2981
Mailing Address - Fax:
Practice Address - Street 1:4711 N BROADWAY ST STE 105
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4908
Practice Address - Country:US
Practice Address - Phone:815-382-2981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program